The Obamacare report card

After six months, the first enrollment season is coming to an end. So it’s time to take stock, with POLITICO’s report card that covers the highs and lows of the rollout.

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If you’re a supporter of the law, you might be cringing right now — you know the areas where the grade is not going to be good. It’s pretty obvious that the Obama administration wasn’t ready for the launch, despite three and a half years to prepare. The political messaging hasn’t impressed anyone; Democrats are scampering away from what was supposed to be a legacy achievement. No one’s going to forget that notion that everyone could keep their plans.

But the critics will have to round out their picture of the law, too. The signups have now hit 6 million — a feat that seemed impossible in the worst days of the website failures — and the administration’s outreach efforts are better than they used to be. And although there are lots of complaints about the prices, some low-income customers seem to be genuinely happy with the rates and subsidies they’re getting.

It’s also important to judge the rollout against the political headwinds the law has faced. White House officials argue that the battles against Obamacare have been stronger and longer lasting than even the fights against breakthroughs like Social Security and civil rights laws. “There’s no other law that has had to overcome all the obstacles that have been thrown at this law by its opponents,” said White House health care adviser Phil Schiliro.

But this is also a program that will affect millions of Americans, and Republicans say it’s such a bad student it should repeat a grade. “For gross incompetence, the thing should be held back a year,” said Brendan Buck, a spokesman for House Speaker John Boehner. “The law is clearly not ready for prime time — not that it ever will be — and that’s why the House has voted to delay it.”

Here’s where Obamacare was a good student and where it needs to show more effort, based on the latest research and interviews with health care experts across the board:

Enrollment

At this point, it’s all about expectations — and after months of lowering the bar, the White House has finally cleared it.

Thanks to the fumbled launch and an unspectacular February, health care experts had been convinced that the total enrollment would be roughly five and a half million people. That turned around quickly once the enrollment websites became flooded with last-minute signups, as the White House had predicted.

And on Thursday, President Barack Obama had his best day in months when the total hit 6 million, earlier than even optimistic experts thought it would.

That’s not nothing. It’s a big recovery from October, and it’s enough to avoid a financial disaster for the insurers. It’s certainly enough to give Democrats the talking point they want against Republicans: “Do you really want to take health insurance away from millions of people?”

It’s just not the original 7 million goal, as declared by Health and Human Services Secretary Kathleen Sebelius, and Republicans won’t ever let the administration forget it. (There was even a time when CBO was predicting 8 million, right when the law passed.)

Keep in mind , too, that enrollment numbers will come down if people don’t pay their premiums — currently as many as 15 percent to 20 percent of those who have signed up haven’t paid up. Numbers could also tick up during the rest of the year, because people can sign up later in special cases like getting married or having a baby, just like they can with workplace insurance.

Those aren’t the only people getting coverage. Another 4.4 million people who visited the exchanges are eligible for Medicaid and the Children’s Health Insurance Program. More are signing up through state Medicaid agencies. But that may fall short of expectations, too — CBO predicted 8 million people in Medicaid in the first year.

So yes, the Obama administration needlessly lost almost two months because of an incompetent website — but the last-minute numbers show it has made up a lot of lost ground since then.

Grade: A-

Mix of customers

It’s not where it needs to be — yet.

To keep premiums stable, health plans need a good mix of healthy customers to help pay for the sicker ones. Until they actually start racking up medical bills, the best substitute we have is to look at the ages of the people who have signed up. And so far, they’ve trended older.

By the end of February, 25 percent of the health exchange customers were ages 18 through 34, and 69 percent of them were 35 or older. That varies from state to state, of course, but overall the exchanges have been underperforming in signing up young adults.

According to the Kaiser Family Foundation, the 18-to-34 adults make up 40 percent of the potential market for individual health insurance, while 54 percent are age 35 or older. That doesn’t mean the final mix has to line up exactly that way, but it’s not going to build confidence among insurers if the young adults don’t sign up in greater numbers.

Obama himself says the age mix is important. The enrollment is already big enough to keep premiums “stable,” but “the impact in terms of the program has always been based more on the mix of people who sign up,” Obama told WebMD earlier this month.

Still, there are mechanisms built into the law to help insurers who don’t get enough healthy people in the first three years — and health insurers knew that going in. “I don’t think plans got into this thinking everything was just going to work out in the first year,” said Mark McClellan, who ran the Medicare agency under President George W. Bush and presided over the start of the Medicare drug benefit.

And there could still be a big surge in the next few days as 20-something procrastinators finally sign up — there’s some evidence that it’s already happening outside the official health exchanges. But it would have to be pretty big to change the mix significantly. So for now, it, too, gets a “not bad but not great” grade.

There’s still a pretty broad disagreement about how many uninsured people are getting covered, which is much of the point of the law. But there are signs of at least some progress.

Gallup surveys have now found the uninsured rate declining three months in a row. In the latest survey, released earlier this month, 15.9 percent of Americans were uninsured, down from 17.1 percent in the last quarter of 2013. Health care analysts were cautious about the first surveys, warning that it could be a one-time dip, but that becomes less likely with each survey that finds the same results.

The studies by McKinsey and Co. tell a different story. In a survey released earlier this month, more than seven out of 10 of Obamacare’s new customers had health insurance before, and just 27 percent were previously uninsured. That was up a bit from its January survey, when only 11 percent were previously uninsured.

None of those surveys tell us exactly what we need to know. McKinsey doesn’t include Medicaid, and Gallup doesn’t prove exactly why the uninsured rate dropped.

And since the Obama administration isn’t tracking the progress on the uninsured in real time, we’re probably going to have to wait a long time for more definitive numbers, however maddening that is.

Grade: Incomplete

Readiness

There’s no point in spending a lot of time on this one. Does anyone really believe the Obama administration was ready to launch the biggest program of Obama’s presidency on Oct. 1? Even the president doesn’t think that anymore.

The administration needed to prove that government can still do big things. As Obama said on the day he signed the Affordable Care Act into law in March 2010: “We are not a nation that does what’s easy … We are a nation that does what is hard. What is necessary. What is right.” The disastrous launch of the federal enrollment website gave the whole program a reputation of incompetence — and once a program has earned that kind of reputation, it’s just about impossible to shake it off completely.

Grade: F

Website repairs

Once it became clear how badly HealthCare.gov was built, the administration scrambled an all-out repair effort that, against the odds, helped the federal website make a remarkable recovery.

For customers, at least, the website became much more user-friendly by the end of November than just about anyone expected. The administration didn’t have to scrap the website after all, a prospect that even Obama reportedly considered. Now, just about anyone who wants to can actually sign up for health coverage. And so far, at least, it's holding up under the crush of last-minute traffic.

If that were the end of the story, the administration might get an A+ for the repair effort. But it’s impossible to ignore the fact that the “back end” of the website still isn’t built. Customers don’t see those sections — but insurers do. Those are the parts that handle the payment of Obamacare subsidies to the insurers, the compensation for health plans that draw too many sick people and the confirmation of each enrollment.

So there’s a lot of manual work being done to take care of all that. For example, one industry source says health insurers are having to use “glorified Excel spreadsheets” to request their subsidy payments.

It’s almost as if the Obama administration did a big extra credit project, raised its grade, and then blew off some homework. It gave the highest priority to the most important part: fixing the customer side. But was it really too much to ask that the whole website would be ready after three and a half years of lead time?